monitoring: what, when and how long? george ntaios university of thessaly, larissa, greece
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Monitoring:
What, when and how long?
George Ntaios
University of Thessaly, Larissa, Greece
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Disclosures
Scholarships: European Stroke Organization; Hellenic Society of Atherosclerosis.Honoraria: Medtronic; Quintiles; Boehringer-Ingelheim.Speaker fees: Sanofi; Boehringer-Ingelheim; Galenica; Bayer.Support for educational events: Bayer; Sanofi-Aventis; Pfizer; Lundbeck; Boehringer-Ingelheim; Galenica; Elpen; Bristol Myers Squibb. Participation in trials:
– NAVIGATE-ESUS / National coordinator (Greece)– PRECIOUS / National coordinator (Greece).– ENOS / National coordinator (Greece).– BIOSIGNAL / Principal Investigator (Larissa).– EBBINGHAUS / Principal Investigator (Larissa).– FOURIER / Principal investigator (Larissa).– PREVISE / Principal investigator (Larissa).– GLORIA-AF / Sub-investigator (Larissa).
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Stroke is an earthquake
San Francisco Bay Area, California, USA. August 24, 2014 10:20 AM
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Why monitor?
Monitor
Diagnostic reasons
Vital signs & complications
Response to treatment
ECG
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Monitor for diagnostic reasons
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Continuous ECG monitoring vs. Holter
Rizos. Stroke 2012; 43:2689-94
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Rizos. Stroke 2012; 43:2689-94
Continuous monitoring vs. Holter
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Sanna. N Engl J Med 2014;370:2478-86
CRYSTAL-AF
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CRYSTAL-AF: the more you look, the more you find
Sanna. N Engl J Med 2014;370:2478-86
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EMBRACE
Gladstone. N Engl J Med 2014;370:2467-77
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EMBRACE : the more you look, the more you find
Gladstone. N Engl J Med 2014;370:2467-77
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Monitor ECG – for how long?
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Gladstone. Stroke 2015; 46:936-41
Atrial extrasystoles predict AF
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Gladstone. Stroke 2015; 46:936-41
Atrial extrasystoles predict AF
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Gladstone. Stroke 2015; 46:936-41
Atrial extrasystoles predict AF
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Monitor ECG in lacunar strokes ?
Sacco. Neurology 2006; 66:1335-8
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Why monitor?
Monitor
Diagnostic reasons
Vital signs & complications
Response to treatment
ECGMicroemboli
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Monitor for diagnostic reasons
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Microemboli monitoring
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Microemboli monitoring
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Why monitor?
Monitor
Diagnostic reasons
Vital signs & complications
Response to treatment
ECGMicroemboli
Arterial pressure
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Monitor Blood Pressure
Jorgensen. Cerebrovasc Dis 2002;13:204-9
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Monitor Blood Pressure
Vemmos. Journ Intern Med 2004; 255: 257–265
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Monitor Blood Pressure
Sandset. Lancet 2011; 377:741-50
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Monitor Blood Pressure
Sandset. Lancet 2011; 377:741-50
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Monitor Blood Pressure
Sandset. Lancet 2011; 377:741-50
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Monitor Blood Pressure
ENOS. Lancet 2015; 385:617-28
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Monitor Blood Pressure
ENOS. Lancet 2015; 385:617-28
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ESO Guidelines
Cautious BP lowering is recommended in patients with extremely high BPs (>220/120mmHg) (Class IV, GCP)
It is recommended that BP of >185/110mmHg lowered before thrombolysis (Class IV, GCP)
ESO Guidelines. CVD 2008
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Why monitor?
Monitor
Diagnostic reasons
Vital signs & complications
Response to treatment
ECGMicroemboli
Arterial pressureGlucose
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Monitor glycemia
Quinn. Cerebrovasc Dis 2009;27:148–155
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Monitor glycemia
Previously diagnosed DM
Newlydiagnosed DM
Stress hyperglycemia
Fasting Glu ≥ 126Random Glu ≥ 200HbA1c ≥ 6.5%
Fasting Glu ≥ 126Random Glu ≥ 200HbA1c < 6.5%
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Monitor glycemia
Ntaios, Michel. Stroke 2010; 41:2366-70
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Monitor glycemia
Gray. Lancet Neurol 2007; 6: 397–406
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Monitor glycemia
Gray. Lancet Neurol 2007; 6: 397–406
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Insulin treatment – functional outcome
Ntaios, Papavasileiou, Makaritsis, Michel. Int J Stroke 2013
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Insulin treatment - mortality
Ntaios, Papavasileiou, Makaritsis, Michel. Int J Stroke 2013
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Insulin treatment - hypoglycemia
Ntaios, Papavasileiou, Makaritsis, Michel. Int J Stroke 2013
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Monitor glycemia
https://clinicaltrials.gov/ct2/show/NCT01369069
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AHA guidelines
Jausch. Stroke 2013
it is reasonable to treat hyperglycemia to achieve blood glucose levels in a range of 140 to
180 mg/dL and to closely monitor to prevent hypoglycemia in patients with acute
ischemic stroke
(Class IIa; Level of Evidence C).
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Why monitor?
Monitor
Diagnostic reasons
Vital signs & complications
Response to treatment
ECGMicroemboli
Arterial pressureGlucoseDysphagia
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Monitor for dysphagia
Fiberoptic Endoscopic Evaluation of Swallowing (FEES)
Videofluoroscopy
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Monitor for dysphagia
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ESO guidelines
ESO Guidelines. CVD 2008
Swallowing assessment is recommended but there are
insufficient data to recommend a specific approach for
treatment (Class III, GCP)
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Why monitor?
Monitor
Diagnostic reasons
Vital signs & complications
Response to treatment
ECGMicroemboli
Arterial pressureGlucoseDysphagiaTemperature
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Monitor temperature
Kakaletsis/Ntaios/Michel. Larissa 2015
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Monitor temperature
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Why monitor?
Monitor
Diagnostic reasons
Vital signs & complications
Response to treatment
ECGMicroemboli
Arterial pressureGlucoseDysphagiaTemperatureOxygen
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ESO guidelines
ESO Guidelines. CVD 2008
Intermittent monitoring of oxygen saturation is recommended
for 72 h in patients with significant persisting neurological
deficits (Class IV, GCP)
It is recommended that oxygen should be administered if the
oxygen saturation falls <95% (Class IV, GCP)
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Monitor 02
Roffe. Nice 2014
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Why monitor?
Monitor
Diagnostic reasons
Vital signs & complications
Response to treatment
ECGMicroemboli
Arterial pressureGlucoseDysphagiaTemperatureOxygenLab tests (CRP, WBC…)Clinically
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Monitor clinically
- Physical examination- Neurological status
- NIHSS- yawning- vomit- headache- GCS
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Why monitor?
Monitor
Diagnostic reasons
Vital signs & complications
Response to treatment
ECGMicroemboli
Arterial pressureGlucoseDysphagiaTemperatureOxygenLab tests (CRP, WBC…)Clinically
Repeat imaging
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Stroke unit works
Langhorne, Cochrane 2009; CD000197
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One size does not fit all
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Take-home messages
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